Why Long Term Disability Carriers Decisions Should Not Be Given Deference in Denying a Long Term Disability Claim

The Saffron vs. Wells Fargo & Company LTD Plan 209 US District Lexis 84152 (C.D.CAL. September 15, 2009), is one of my favorite cases. As a Long Term Disability attorney that deals with MetLife decisions denying claims, the Saffron case provided an interesting road map for determining whether or not MetLife should be given any deference in their denial decision.

While this is a California case and not binding on the district courts in the 11th Circuit there are some interesting things to consider.

The Saffron court noted that the district court could consider:

1. Whether MetLife ignored Ms. Saffron’s complaints of pain, which were inherently subjective and not easily determined by objective measurement.

2. Whether MetLife had a meaningful dialogue with Ms. Saffron in deciding whether to grant or deny benefits.

3. Whether MetLife took various statements of the plaintiff’s doctors out of context otherwise distorted them or omitted important qualifiers.

Of course MetLife, in my opinion, is always guilty of these problems.

The Saffron court noted that “pain is a completely subjective phenomena and can’t be objectively verified or measured,” (Saffron vs. Wells Fargo 522f3D.873). The court noted that objective evidence of pain really wasn’t available with regard to the kind of claim Ms. Saffron had and MetLife’s insistence that it produced was a negative factor in the courts views, MetLife also sent a canned determination letter. It did suggest that she could appeal by “providing objective medical information to support your inability to perform the duties or her occupation,” it didn’t explain why the information that Ms. Saffron had already provided was insufficient, that certainly would have taken the guess work out Ms. Saffron appeal (Saffron 522f3d870).

As usual, MetLife relied on peer reviewed medical opinion of a Dr. Thomas and Dr. Menotti. Dr. Thomas commented that the medical evidence in Ms. Saffron’s file lacked “clear, sequential, detailed, objective clinical information that could completely preclude Ms. Saffron from an attempt at return to work.” The court, in a humorous not that this was “little more than a long series of unconnected adjectives.” They commented that how “absence of information could preclude Ms. Saffron from returning to work but, the function of the word sequential played in the litany, but why the treating physicians report and attached medical information wasn’t clear,” was “left to the imagination.” Dr. Menotti was “unconvinced” that Ms. Saffron’s “self reported headaches and chronic pain syndrome” had been enough to stop her from working. Dr. Menotti did not explain why he was unconvinced or what her treating physicians or Ms. Saffron needed to do to “convince Dr. Menotti” (Saffron, 522f3d871).

MetLife also sent out a final denial letter suggesting at that time that she should have a functional capacity evaluation. That was really too late because MetLife wouldn’t have considered it anyway.

MetLife also noted that the MRI done on January 12, 2002 and April 28, 2003 were unchanged and there was no “progression of degeneration” in the document.

MetLife had paid Ms. Saffron benefits based on the January 12, 2002 MRI, MetLife did not explain “further degeneration” was necessary to show that she was disabled.

As the court noted, in order to find her no longer disabled one would “expect the MRIs to show improvement, not a lack of degeneration,” (Saffron 522f3d871). You can see that the court recognized the gobblygook “reasoning” that MetLife uses in denying a valid Long Term Disability claims. They ignore complaints of pain, they don’t explain what documentation you need to present to evaluate the claim and of course they take your doctors statements out of context, distort them or have their physicians render gobblygook opinions.

If you have received a gobblygook denial letter, you only have 180 days to perfect an appeal. Contact Long Term Disability ERISA attorney Nancy Cavey, who is based in the Tampa Bay area, to help you perfect your appeal.

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